INTERNATIONAL JOURNAL OF
ENVIRONMENTAL RESEARCH
AND PUBLIC HEALTH
Article
Oral Health-Related Knowledge, Attitudes and Behaviours
of Elementary School Teachers
1,
Gülçin Yılmaz *, Abanoub Riad
Citation: Yılmaz, G.; Riad, A.; Krsek,
M.; Kurt, H.; Attia, S. Oral Health-
Related Knowledge, Attitudes and
Behaviours of Elementary School
Teachers. Int. J. Environ. Res. Public
Health 2021, 18, 6028. https://
doi.org/10.3390/ijerph18116028
Academic Editors: Alessandro Nota
and Simona Tecco
Received: 30 April 2021
Accepted: 1 June 2021
Published: 3 June 2021
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Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
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4.0/).
Int. J. Environ. Res. Public Health 2021, 18, 6028. https://doi.org/10.3390/ijerph18116028
2 2 1 3,
, Martin Krsek , Hanefı Kurt and Sameh Attia *
1 Department of Prosthodontics, Faculty of Dentistry, Istanbul Medipol University, Istanbul 34810, Turkey;
hkurt@medipol.edu.tr
2 Department of Public Health, Faculty of Medicine, Masaryk University, 62500 Brno, Czech
Republic; abanoub.riad@med.muni.cz (A.R.); krsek@med.muni.cz (M.K.)
3 Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Klinikstrasse 33,
35392 Giessen, Germany
* Correspondence: gulcin.yilmaz@std.medipol.edu.tr (G.Y.); sameh.attia@dentist.med.uni-giessen.de (S.A.)
Abstract: Background: elementary schoolteachers play a central role in shaping their students’ beliefs,
attitudes, and behaviours related to health and oral hygiene. This study was designed to evaluate
Turkish schoolteachers’ levels of oral health knowledge, attitudes, and behaviours. Methods: A cross-
sectional survey-based study was conducted among elementary schoolteachers in Istanbul using a
validated self-administered questionnaire. The questionnaire was composed of 36 multiple-choice items
categorised into six sections, and the participants were recruited using convenience sampling.
(3) Results: A total of 385 elementary schoolteachers participated in this study. The majority were
female (62.2%), qualified with a licensure degree (81.3%) and working in public schools (86.5%).
Female gender and greater work experience were found to be promoters for oral health knowledge
and positive attitudes. The correlation between their perceived knowledge and actual knowledge
was very weak, thus suggesting that the teachers are inclined to overestimate their knowledge.
Conclusions: The Turkish elementary schoolteachers showed satisfactory oral health knowledge
and attitudes toward oral health education. The teachers’ knowledge about dental trauma
management was inadequate, necessitating urgent educational interventions, especially for
physical education teachers, who are at the greatest risk of encountering such events during their
work. The oral hygiene behaviours were not associated with teachers’ oral health knowledge,
attitudes, or practice, thus requiring further investigation.
Keywords: attitude to health; behavior; oral health; oral hygiene; schoolteachers; turkey; wounds
and injuries
1. Introduction
stays
Oral hygiene measures in childhood lead to healthy teeth and oral mucosa,
and providing optimal general health conditions [1]. Oral diseases are depicted as a major
public health challenge, especially in school children. A total of 90% of them are
suffering from dental caries, with increasing incidences in Asian and Latin American
countries as reported by the Global Burden of Disease (GBD) in its 2005 report [ 2]. The
prevalence of tooth decay in school children ranged between 60 and 90%. The incidence
of caries is rising rapidly in developing countries [2].
It had been reported by the United Nations Educational, Scientific and Cultural
Organization (UNESCO) that the number of teachers at the primary school level world-
wide by the year 1993 was around 23.9 million [3]. Schools continue to be an essential
environment, offering an ideal and effective method to manage over 1 billion children
worldwide [4]. Preschools and primary schools have great potential to influence child’s
health behaviour [5,6]. Children spend a significant amount of time at school, especially
https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 6028 2 of 18

at the age when their habits are shaped. Therefore, the role of teachers is critical in
these developmental stages of the child [7].
The education of school-age children in oral health is crucial because healthy oral
habits occur at a young age. The importance of teaching children (infants, preschoolers,
or schoolchildren) about oral hygiene was recognised as early as 1878 [8,9]. Schools are
an optimal location for providing oral health education, as these services can be given
similarly and widely to all children, especially those who do not have access to other
health resources and cannot receive professional dental care [10,11].
One of the critical issues in oral health is the treatment of dental injuries [12].
Children participate in sports activities at school, and in cases of close contact or
physical activity, injuries may occur due to reasons such as falls or accidents [13]. In
these trauma cases, successful management of the process from the moment of the
event to the visit to the dentist significantly increases the chances of successful post-
trauma treatments [14]. The good management of this process depends on the teacher’s
level of knowledge. Correct guidance of the child and their parents can give the dentist a
chance for early intervention. A teacher needs to know what to do in an emergency
regarding primary and permanent teeth [15]. Dental trauma in industrialised countries
ranges from 16 to 40% for six-year-olds and 4 to 33% for 12- to 14-year-olds; in some
Latin American countries, it is about 15% of schoolchildren; in the Middle East, it is about
5 to 12% among 6- to 12-year-olds [16]. Many studies have shown that getting support
from teachers is successful in improving the oral health of school children [17].
However, according to some reports, teachers were hesitant to participate in oral
health programs that require supervision [18]. The reason for this is thought to be due to
the teachers’ lack of knowledge on oral health [19]. Since schoolteachers are models for
school students, their oral health knowledge must be good, and their oral health
behaviours and attitudes must follow professional advice [1]. For this reason, their
knowledge and attitudes about oral health are important both for their oral health and for
the children they influence and teach as a model [6]. Oral health is an integral part of
overall health and well-being. Individuals with a healthy mouth live without pain,
discomfort, and embarrassment while talking, eating, and socialising [20,21]. One study
showed that school-age adolescents suffering from poor oral health were 12 times more
often deprived of activities compared to their peers [22]. More than 50 million school
classes are lost worldwide due to poor oral health. This can affect the student’s school
performance and subsequent success in his life [23]. Ideally, primary schoolteachers can
give information about good oral health, dental and gum care, proper oral hygiene, use of
fluoride, proper dietary advice, and the benefit of routine dental visits [24]. The goal of
oral health education is to improve knowledge within the target population, leading them
to be individuals with better oral health and to adopt positive oral health behaviours [16].
Recent studies revealed that oral-health promotion programs have a significant
effect in improving dental health status and reducing the cost of healthcare systems.
Therefore, oral-health promotion programs revealed their effects on children’s oral health
and on parental dental treatment expenses [25]. Education in and through the media had
an increasing tendency that can be seen in most health-promoting media literacy classes
being taught in schools [26]. In order to prevent the spread of infectious diseases, health
personnel are advised to use audiovisual media to educate the population about health
[27]. Mass media campaigns tend to be helpful in influencing beliefs of the general public
and healthcare practitioners by increasing the alignment between beliefs and current
evidence and promoting self-management concepts [28].

2. Materials and Methods

2.1. Design
This study was conducted in Istanbul, Turkey, between July and September 2020 as an
analytical cross-sectional survey-based study using an online self-administered questionnaire
(SAQ) of multiple-choice items in order to evaluate the oral health self-
Int. J. Environ. Res. Public Health 2021, 18, 6028 3 of 18

perceived knowledge, actual knowledge, attitudes, behaviours, and practice of

elementary school teachers. The questionnaire was electronically developed using
SurveyMonkey (SVMK Inc. San Mateo, CA, USA 2020), and the target subjects received
a uniform resource locator (URL) and a quick response (QR) code from their school
administrator/principal to take part in the study.

2.2. Participants
According to the official data of the Istanbul governorship, as of May 2019, there
were 3,175,285 students enrolled in 7437 schools (3790 private and 3647 publicly
funded) with 168,527 teachers. The adequate sample size for this study was calculated
using Epi InfoTM version 7.2.4 (CDC. Atlanta, GA, USA 2020), which indicated that a
total of 384 teachers was required in order to achieve conclusive results with a
confidence level of 95% and an error margin of 5%. Participation in this study was
entirely voluntary and not financially compensated or incentivised by other means to
minimise self-selection bias. The participants were able to withdraw from the study at any
time without the need to explain the reason.

2.3. Instrument
The items of the SAQ used in this study were adopted from previous studies with
relevant purposes, including the assessment of schoolteachers’ oral health knowledge
and attitudes, assessment of schoolteachers’ knowledge and practice regarding dental
injuries, and evaluation of oral hygiene behaviours [1,2,5–7]. The instrument’s content
validity was evaluated by a panel of experts in dental public health who reviewed the
proposed items in terms of clarity and relevance.
The SAQ had 36 multiple-choice items categorised into six sections. Section I (five
items) was about demographic data such as gender, length of work experience, education
status and branch. Section II (four items) was about perceived oral health knowledge
assessed by a five-point Likert scale ranging from totally disagree to totally agree. Section
III (10 items) was about actual oral health knowledge, which was designed to correlate with
the items of Section II. Section IV (four items) was about the attitudes towards oral health
education assessed by a five-point Likert scale ranging from totally disagree to totally agree.
Section V (five items) was adapted from Hiroshima University Dental Behavioral Inventory
(HU-DBI) aiming to evaluate oral health behaviours [29]. Section VI (eight items) was about
the teachers’ experience and practice of oral health education (Supplementary Materials).

2.4. Ethics
This study was conducted following the Declaration of Helsinki for the ethical prin-
ciples of medical research involving human subjects. It was reported according to the
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) state-
ment for cross-sectional studies [30,31]. Ethical approval was granted by the institutional
review board (IRB) of Istanbul Medipol University under the code of 10840098-772.02-
E.34168 on 8 July 2020. Written permission was obtained from each participating
school’s principal/administrator to carry out the survey; electronic informed consent was
required from each invited teacher before filling in the questionnaire.

2.5. Statistics
All statistical analyses were performed using the Statistical Package for the Social
Sciences (SPSS) version 27.0 (SPSS Inc., Chicago, IL, USA, 2020). Descriptive
statistics were carried out primarily for the normality of data, followed by the frequencies,
percentages and central tendencies of demographic variables, oral health-related
knowledge, attitudes, behaviours, and practice.
For the total score of actual knowledge, each question had one point for the correct
answer and zero points for wrong answers. The total score of perceived knowledge and the
total score of attitudes were calculated by pooling the scores of each question in these
Int. J. Environ. Res. Public Health 2021, 18, 6028 4 of 18

sections that were originally rated by a five-point Likert scale. For the total score of oral
hygiene behaviors, one point was given for the favorable behavior and zero points were
given to the unfavorable behavior.
2
Consequently, inferential statistics were carried out using the Chi-squared test (c ),
Mann–Whitney test (U), and Kruskal–Wallis (H) test to evaluate the impact of
demographic variables on teachers’ oral health knowledge, attitudes, and behaviours.
Spearman’s correlation test (r) was performed to evaluate the association between actual
knowledge domains and perceived knowledge items. The strengths of correlation are
described by the value of (r): 0.01 to 0.39 “weak”; 0.40 to 0.69 “moderate”; 0.70 to 0.99
“strong”; 1.0 “perfect” [32]. All inferential tests were carried out with a confidence level of
95% and significance value p 0.05.

3. Results
3.1. Demographic Characteristics
A total of 385 elementary schoolteachers from Istanbul, Turkey, participated in this
study. The majority were females (62.2%), qualified with a licensure degree (81.3%) and
working in public schools (86.5%). While 87 (22.6%) participants had one to five years of
work experience, 111 (28.8%) have worked for 6 to 10 years, 89 (23.1%) had worked for
11 to 20 years, and 98 (25.5%) had worked for over 20 years. Eleven (2.9%) participants
were teachers of physical education (Table 1).

Table 1. Demographic characteristics of elementary schoolteachers, Istanbul, Turkey, 2020.

Variable Outcome Frequency Percentage Cumulative Percentage

Gender Female 241 62.2% 62.2%
Male 144 37.4% 100%
1–5 years 87 22.6% 22.6%
Experience 6–10 years 111 28.8% 51.4%
11–20 years 89 23.1% 74.5%
>20 years 98 25.5% 100%
License 313 81.3% 81.3%
Qualification Masters 66 17.1% 98.4%
Other 6 1.6% 100%
School Type Public 333 86.5% 86.5%
Private 52 13.5% 100%
Physical 11 2.9% 2.9%
Branch Education
Other 312 97.1% 100%

3.2. Oral Health-Related Knowledge

Oral health-related knowledge of teachers was evaluated in two main constructs—
self-perceived knowledge and actual knowledge. Perceived knowledge is one’s self-
assessment or feeling of knowing the information, and it should be distinguished from
and assessed concurrently with actual knowledge in order to find out any knowledge
discrepancies that indicate “knowledge illusion” [33–35]. The four domains of knowledge
tested in this study were (i) primary dentition, (ii) oral diseases risk factors, (iii) oral
hygiene methods, and (iv) dental trauma management.
Regarding their perceived knowledge, 76.6%, 64.2%, 82.3%, and 36.9% of the partici-
pants agreed that they have sufficient knowledge about primary dentition, oral diseases risk
factors, oral hygiene methods, and dental trauma management, respectively. The teach-ers
with >10 years of work experience had higher levels of perceived knowledge in all four
knowledge domains (U = 15,919, 14,819.5, 17,994.5, and 14,663.5; p = 0.01, <0.001, 0.589,
and <0.001, respectively) than their colleagues with 10 years of experience. Female teachers had
higher levels of all four perceived knowledge domains (U 13,690, 15,446, 14,602, and
Int. J. Environ. Res. Public Health 2021, 18, 6028 5 of 18

16,976; p < 0.001, 0.054, 0.003, and 0.706, respectively) than their male colleagues. In
general, the teachers at private schools had higher perceived knowledge levels than the
teachers at public schools.
Regarding their actual knowledge, the participants had to answer 10 multiple choice
questions with one correct answer (two items: primary dentition; four items: oral diseases
risk factors; two items: oral hygiene methods; two items: dental trauma management). All
items of the second (oral diseases risk factors) and third domain (oral hygiene methods)
were correctly answered by more than 50% of the participants. The two items of the
fourth domain (dental trauma management) received the least number of correct
answers 26% and 32.5%, respectively. The teachers with 10 years of experience had a
significantly higher level of actual knowledge in the first domain (U = 16,446; p = 0.043)
and a lower level in the fourth domain (U = 14,924; p = 0.007) than their colleagues with
>10 years of experience. Female teachers had a significantly higher level of actual
knowledge in the second domain (U = 13,648.5; p < 0.001) than their male colleagues.
The difference between private schoolteachers and public schoolteachers in actual
knowledge domains was not statistically significant (Table 2).

Table 2. Oral health-related knowledge of elementary schoolteachers stratified by work experience, Istanbul, Turkey, 2020.

Item Outcome 10 Years >10 Years Total Significance

Perceived Knowledge
Strongly Agree 38(19.2%) 62(33.2%) 100 (26%)
Agree 110 (55.6%) 85(45.5%) 195 (50.6%)
I am aware enough of primary Not Sure 39(19.7%) 35(18.7%) 74 (19.2%)
teeth Disagree 11 (5.6%) 3(1.6%) 14 (3.6%)
Strongly Disagree 0 (0%) 2(1.1%) 2 (0.5%)
(1–5) 3.88 0.78 4.08 0.82 3.98 0.8 0.010
Strongly Agree 26(13.1%) 44(23.5%) 70 (18.2%)
Agree 85(42.9%) 92(49.2%) 177 (46%)
I am aware enough of oral Not Sure 67(33.8%) 38(20.3%) 105 (27.3%)
diseases etiologies Disagree 17 (8.6%) 10 (5.3%) 27 (7%)
Strongly Disagree 3(1.5%) 3(1.6%) 6 (1.6%)
(1–5) 3.58 0.88 3.88 0.89 3.72 0.9 <0.001
Strongly Agree 38(19.2%) 49(26.2%) 87 (22.6%)
I am aware enough of oral Agree 129 (65.2%) 101 (54%) 230 (59.7%)
Not Sure 22(11.1%) 29(15.5%) 51 (13.2%)
hygiene methods Disagree 7(3.5%) 6(3.2%) 13 (3.4%)
Strongly Disagree 2 (1%) 2(1.1%) 4 (1%)
(1–5) 3.98 0.73 4.01 0.8 3.99 0.77 0.589
Strongly Agree 11 (5.6%) 20(10.7%) 31 (8.1%)
I am aware enough of what to do Agree 48(24.2%) 63(33.7%) 111 (28.8%)
Not Sure 88(44.4%) 81 (43.%) 169 (43.9%)
in case of tooth injury (dental
Disagree 41(20.7%) 17 (9.1%) 58 (15.1%)
trauma)
Strongly Disagree 10 (5.1%) 6(3.2%) 16 (4.2%)
(1–5) 3.05 0.94 3.40 0.91 3.22 0.94 <0.001
Int. J. Environ. Res. Public Health 2021, 18, 6028 6 of 18

Table 2. Cont.

Item Outcome 10 Years >10 Years Total Significance

Actual Knowledge
Number of primary teeth True 89 (44.9%) 72 (38.5%) 161 (41.8%) 0.200
First permanent tooth True 95 (48%) 71 (38%) 166 (43.1%) 0.047
Caries of primary teeth True 103 (52%) 114 (61%) 217 (56.4%) 0.077
Sweet snacks True 177 (89.4%) 163 (87.2%) 340 (88.3%) 0.496
Acidic food True 180 (90.9%) 171 (91.4%) 351 (91.2%) 0.853
Thumb sucking True 141 (71.2%) 145 (77.5%) 286 (74.3%) 0.156
Dental attendance frequency True 149 (75.3%) 134 (71.7%) 283 (73.5%) 0.424
Oral hygiene aids True 118 (59.6%) 98 (52.4%) 216 (56.1%) 0.155
Avulsed tooth medium True 41 (20.7%) 59 (31.6%) 100 (26%) 0.015
Avulsed tooth replantation True 55 (27.8%) 70 (37.4%) 125 (32.5%) 0.043
Knowledge Domain No. 1 (0–2) 0.93 0.8 0.76 0.75 0.85 0.78 0.043
Knowledge Domain No. 2 (0–4) 3.04 1.15 3.17 1.16 3.1 1.15 0.084
Knowledge Domain No. 3 (0–2) 1.35 0.71 1.24 0.67 1.3 0.69 0.081
Knowledge Domain No. 4 (0–2) 0.48 0.72 0.69 0.8 0.58 0.77 0.007
Total (0–10) 5.8 1.63 5.87 1.82 5.83 1.76 0.651
2
Chi-squared test (c ) and Mann–Whitney (U) test were used with a significance level of 0.05.

3.3. Oral Hygiene Behaviours

Oral hygiene behaviours were evaluated using five items adapted from the Turkish
version of HU-DBI (items no. 1, 4, 9, 12, and 16) [29,36]. While 243 (63.1%) participants
reported that they do not worry about visiting the dentist, only 29 (7.5%) and 50 (13%) of
them had used disclosing dye and a child-sized toothbrush. The teachers with 10 years
2
of experience had a lower level of calculus detection (c = 9.87; p = 0.002) compared to
their colleagues with >10 years of experience. For the total behaviours score (0–5), no
significant difference was found between participants in terms of gender, work
experience, or school type (Table 3).

Table 3. Oral health-related behaviours of elementary schoolteachers stratified by work experience.

Item Outcome 10 Years >10 Years Total Significance

I have noticed white stick deposits on my teeth Disagree 98 (49.5%) 63 (33.7%) 161 (41.8%) 0.002
I use a child-sized toothbrush Agree 20 (10.1%) 30 (16%) 50 (13%) 0.083
I have used a dye to see how clean my teeth are Agree 8 (4%) 21 (11.2%) 29 (7.5%) 0.008
I put off going to the dentist until I have toothache Disagree 106 (53.5%) 97 (51.9%) 203 (52.7%) 0.744
I do not worry about visiting the dentist Agree 117 (59.1%) 126 (67.4%) 243 (63.1%) 0.092
Total (0–5) 1.76 0.95 1.8 0.95 1.78 0.95 0.739
2
Chi-squared test (c ) and Mann–Whitney (U) test were used with a significance level of 0.05.

3.4. Oral Health Education Attitudes

The schoolteachers’ attitudes towards providing oral health education to their
students were evaluated by four items assessed by a five-point Likert scale ranging from
“strongly agree = 5 “to “strongly disagree = 1”. A total of 311 (80.8%) participants agreed
that teachers should have a role in the oral health education of schoolchildren. The
2
teachers with 10 years of experience (74.3%) had a significantly (c = 11.22; p < 0.001)
lower level of acceptance for their proposed role in providing oral health education
compared to their colleagues with >10 years of experience (87.7%). A total of 294
(76.4%) participants agreed that teachers should receive oral health training as a part of
general health training. The teachers with 10 years of experience (70.7%) had a
2
significantly (c = 7.23; p = 0.007) lower level of willingness for receiving oral health training
compared to their colleagues with >10 years of experience (82.4%).
Int. J. Environ. Res. Public Health 2021, 18, 6028 7 of 18

A total of 334 (86.8%) participants believed that oral health could affect the
psychology of schoolchildren. The teachers with 10 years of experience (89.4%) had an
2
insignificantly (c = 3.01; p = 0.083) lower level of belief of oral health impact on
schoolchildren’s psy-chology compared to their colleagues with >10 years of experience
(89.8%). A total of 351 (91.2%) participants agreed that oral health education could
benefit their schoolchil-dren. The teachers with 10 years of experience (83.8%) had an
2
insignificantly (c = 1.60; p = 0.207) lower level of belief of oral health benefits for their
schoolchildren compared to their colleagues with >10 years of experience (93%). There
was no significant difference between participants in any of the attitude items according
to gender (female vs. male) or type of school (public vs. private) (Table 4).

Table 4. Oral health-related attitudes of elementary schoolteachers stratified by work experience.

Item Outcome 10 Years >10 Years Total Significance

Strongly Agree 52 (26.3%) 56(29.9%) 108 (28.1%)
Agree 95 (48%) 108 (57.8%) 203 (52.7%)
Do you think that teachers should have a role in Not Sure 30 (15.2%) 15 (8%) 45 (11.7%)
Disagree 19 (9.6%) 6(3.2%) 25 (6.5%)
oral health education of schoolchildren? Strongly 2 (1%) 2(1.1%) 4 (1%)
Disagree
(1–5) 3.89 0.94 4.12 0.77 4 0.87 0.017
Strongly Agree 44 (22.2%) 48(25.7%) 92(23.9%)
Agree 96 (48.5%) 106 (56.7%) 202 (52.5%)
Not Sure 38 (19.2%) 17(9.1%) 55(14.3%)
Do you think teachers should receive oral health
Disagree 16 (8.1%) 11(5.9%) 27 (7%)
training as a part of general health training?
Strongly 4 (2%) 5(2.7%) 9(2.3%)
Disagree
(1–5) 3.81 0.94 3.97 0.91 3.89 0.93 0.048
Strongly Agree 52 (26.3%) 51(27.3%) 103 (26.8%)
Agree 114 (57.6%) 117 (62.6%) 231 (60%)
Do you think oral health can affect the Not Sure 20 (10.1%) 13 (7%) 33 (8.6%)
Disagree 10 (5.1%) 3(%1.6) 13 (3.4%)
psychology of schoolchildren?
Strongly
2 (1%) 3(1.6%) 5 (1.3%)
Disagree
(1–5) 4.03 0.81 4.12 0.73 4.08 0.76 0.303
Strongly Agree 65 (32.8%) 76(40.9%) 141 (36.7%)
Agree 112 (56.6%) 98(52.7%) 210 (54.7%)
Do you think oral health education can benefit Not Sure 15 (7.6%) 8(4.3%) 23 (6%)
Disagree 4 (2%) 1(0.5%) 5 (1.3%)
your schoolchildren?
Strongly
2 (1%) 3(1.6%) 5 (1.3%)
Disagree
(1–5) 4.18 0.74 4.31 0.73 4.24 0.73 0.058
Total (5–20) 15.91 16.54 16.21 0.019
2.83 2.48 2.68
Mann-Whitney (U) test was used with a significance level of 0.05.

3.5. Oral Health Education Experience

Only 67 (17.4%) participants reported receiving training on how to provide education in
general hygiene-related topics, with a significant (c2 = 5.48; p = 0.019) difference be-tween
private schoolteachers (28.8%) and public schoolteachers (15.6%), and a significant (c2 =
7.91; p = 0.005) difference between teachers with >10 years of experience (23%) and 10
years of experience (12.1%). An even smaller fraction of participants (9.4%) reported
receiving training on how to provide education in oral hygiene-related topics, without a
significant difference according to the length of work experience (c2 = 2.5; p = 0.114), gender
(c2 = 0.31; p = 0.579), or school type (c2 = 0.34; p = 0.56).
Int. J. Environ. Res. Public Health 2021, 18, 6028 8 of 18

While 51.7% of participants reported supervising the brushing habit of their schoolchil-
dren, only 7.5% reported elevating the upper lip of their schoolchildren to check their teeth.
Regarding their experience with teaching their own schoolchildren about oral health, 110
(28.6%) reported attempting to provide education on topics related to teeth and oral health,
2 2
without a significant difference in terms of work experience (c = 1.58; p = 0.209), gender (c
2
= 0.93; p = 0.334), and school type (c = 0.5; p = 0.479) (Table 5).

Table 5. Oral health education experience of elementary schoolteachers stratified by work experience.

Item Outcome 10 Years >10 Years Total Significance

Education of general hygiene True 24 (12.1%) 43 (23%) 67 (17.4%) 0.005
Education of oral hygiene True 14 (7.1%) 22(11.8%) 36 (9.4%) 0.114
Checking children’s teeth True 10 (5.1%) 19(10.2%) 29 (7.5%) 0.058
Supervising children’s brushing True 102 (51.5%) 97(51.9%) 199 (51.7%) 0.944
Teaching oral health True 51 (25.8%) 59(31.6%) 110 (28.6%) 0.209
Total (0–5) 1.02 1.1 1.28 1.27 1.15 1.19 0.044
Teaching oral health: topics Dental Anatomy 4 (8%) 6 (11.5%) 10 (9.8%) 0.476
Oral Hygiene 42 (84%) 43(82.7%) 85 (83.3%)
Oral Diseases 4 (8%) 3(5.8%) 7 (6.9%)
Teaching oral health: methods Oral Health Videos 27 (52.9%) 41(78.8%) 68 (66%) 0.005
Mouth Models 17 (33.3%) 9 (17.3%) 26 (25.2%)
Printed Posters 7 (13.7%) 2(3.8%) 9 (8.7%)
Teaching oral health: feedback Very Favorable 14 (27.5%) 14(26.4%) 28 (26.9%) 0.902
Favorable 25 (49%) 26(49.1%) 51 (49%)
Not Sure 9 (17.6%) 10(18.9%) 19 (18.3%)
Unfavorable 2 (3.9%) 3(5.7%) 5 (4.8%)
Very Unfavorable 1 (2%) 0 (0%) 1 (1%)
2
Chi-squared test (c ) and Mann–Whitney (U) test were used with a significance level of 0.05.

The most common topic for provided oral health education was oral hygiene (83.3%),
followed by dental anatomy (9.8%) and oral disease (6.9%). While oral health videos (66%)
were the most frequently used method in providing oral health education to schoolchildren,
printed posters (8.7%) were the least common method. Regarding students’ feedback on the
oral health education provided by their teachers, 75.9% had very favourable or favourable
feedback, while only 5.8% had unfavourable or very unfavourable feedback (Figure 1).

3.6. Social Determinants of Oral Health Knowledge, Attitudes, and Behaviours

Female teachers had significantly higher levels of perceived oral health knowledge
(U = 14,266.5; p = 0.003) and actual knowledge (U = 14,713.5; p = 0.011) than their
male colleagues. Similarly, female teachers had insignificantly higher oral hygiene
behaviours (U = 15,983.5; p = 0.175) than their male colleagues. Contrarily, male
teachers had a higher level of attitudes (U = 17,099.5; p = 0.861) towards oral health
education than female colleagues slightly.
The teachers with >10 years of work experience had higher levels of perceived oral
health knowledge (U = 14,864.5; p = 0.001), actual knowledge (U = 18,027.5; p = 0.651),
oral hygiene behaviours (U = 18,166.5; p = 0.739), and oral health education attitudes (U
= 15,917; p = 0.019) than their colleagues with 10 years of experience.
Int. J. Environ. Res. Public Health 2021, 18, 6028 9 of 18

Figure 1. (a) Topics of oral health education provided to schoolchildren; (b) methods used in
providing oral health education to schoolchildren; (c) schoolchildren’s feedback to oral health
education provided by their teachers.

The teachers with a master’s degree had slightly higher levels of perceived oral health
knowledge (U = 10,101; p = 0.776), actual knowledge (U = 9213; p = 0.161), and oral health
Int. J. Environ. Res. Public Health 2021, 18, 6028 10 of 18

education attitudes (U = 9190; p = 0.162) than their colleagues with a licensure

qualification. The only significant difference between teachers with a master’s degree
and teachers with a licensure qualification was only found in terms of oral hygiene
behaviours (U = 8024; p = 0.003).
The teachers at public schools had insignificantly higher levels of actual oral health
knowledge (U = 8212; p = 0.544) and oral hygiene behaviours (U = 7787.5; p = 0.222), while
the teachers at private schools had insignificantly higher levels of perceived oral health
knowledge (U = 7910; p = 0.312) and oral health education attitudes (U = 8513.5; p = 0.871).
The physical education teachers had a significantly lower level of perceived oral
health knowledge (U = 1260; p = 0.027) and actual knowledge (U = 1059; p = 0.005),
and they had an insignificantly lower level oral health education attitudes (U = 2038; p =
0.956) and oral hygiene behaviours (U = 1321; p = 0.107). The physical education
teachers were also the least knowledgeable in all actual knowledge domains, including
dental trauma management (Table 6).

Table 6. Social determinants of elementary schoolteachers’ oral health knowledge, behaviours, and attitudes.

Variable Outcome Perceived Knowledge Actual Knowledge Behaviours Attitudes

Mean SD Significance Mean SD Significance Mean SD Significance Mean SD Significance
Gender Female 15.16 2.73 0.003 6.01 1.76 0.011 1.83 0.99 0.175 16.19 2.78 0.861
Male 14.49 2.54 5.53 1.63 1.70 0.87 16.26 2.51
Experience 10 years 14.48 2.57 0.001 5.80 1.63 0.651 1.76 0.95 0.739 15.91 2.83 0.019
>10 years 15.36 2.71 5.87 1.82 1.80 0.95 16.54 2.48
License 14.87 2.66 5.77 1.71 1.73 0.93 0.006 16.14 2.67 0.306
Qualification Masters 14.95 2.83 0.154 6.14 1.83 0.365 2.09 0.97 16.53 2.77
Other 16.67 1.37 5.83 0.75 1.33 1.03 16.67 2.58
School Type Public 14.85 2.76 0.312 5.85 1.73 0.544 1.80 0.93 0.222 16.20 2.69 0.871
Private 15.31 2.06 5.71 1.68 1.65 0.99 16.31 2.62
Branch Physical 13.18 2.71 4.27 1.95 1.73 1.10 0.956 15.10 3.11 0.107
Education 0.027 0.005
Other 14.96 2.66 5.88 1.70 1.78 0.95 16.24 2.67

Mann–Whitney (U) and Kruskal–Wallis (H) test were used with a significance level of 0.05.

3.7. Correlation between Perceived Knowledge and Actual Knowledge

The overall score of perceived oral health knowledge was weakly correlated with
the overall score of actual oral health knowledge (r = 0.265; p < 0.001). The perceived
knowledge and the actual knowledge were positively correlated in all domains, even
though the relationships between both knowledge constructs were either negligible or
weak (0.008 to 0.274).
Both knowledge constructs were insignificantly (r = 0.080 and 0.071; p = 0.117 and
0.164) correlated in the first (primary dentition) and third domain (oral hygiene methods),
respectively, while they were significantly (r = 0.208 and 0.274; p < 0.001 and < 0.001)
correlated in the second (oral diseases risk factors) and fourth domain (dental trauma
management), respectively.
While actual knowledge of the third domain (oral hygiene methods) was not signif-
icantly correlated with any perceived knowledge domains, the actual knowledge of the
fourth domain (dental trauma management) was significantly correlated with all
perceived knowledge domains (Table 7).
Int. J. Environ. Res. Public Health 2021, 18, 6028 11 of 18

Table 7. Correlation of perceived oral health knowledge and actual knowledge of elementary schoolteachers.

Variable Act. Act. Act. Act. Act. Knowledge

Knowledge I Knowledge II Knowledge III Knowledge IV Total
Prc. Knowledge I r. 0.080 0.203 ** 0.080 0.196 ** 0.264 **
Sig. 0.117 <0.001 0.115 <0.001 <0.001
Prc. Knowledge II r. 0.130 * 0.208 ** 0.025 0.172 ** 0.256 **
Sig. 0.011 <0.001 0.629 0.001 <0.001
Prc. Knowledge III r. 0.046 0.121* 0.071 0.140 * 0.169 **
Sig. 0.369 0.017 0.164 0.006 0.001
Prc. Knowledge IV r. 0.078 0.047 0.008 0.274 ** 0.116 *
Sig. 0.127 0.355 0.880 <0.001 0.023
Prc. Knowledge Total r. 0.130 * 0.177 ** 0.058 0.257 ** 0.265 **
Sig. 0.010 <0.001 0.254 <0.001 <0.001
Prc. = perceived knowledge; Act. = actual knowledge; r. = Spearman’s correlation coefficient; ** correlation is significant at the level
0.01 level (two-tailed); * correlation is significant at the 0.05 level (two-tailed). Sig. = Significance

3.8. Association of Oral Health Knowledge and Behaviours

In all oral hygiene behaviour items of HU-DBI, the level of actual knowledge was
higher in the teachers with favourable hygiene outcomes, except for the item of using
disclosing agents, where the actual knowledge level was equal between the teachers
who used disclosing agents and those who do not use them. Similarly, the level of
perceived knowledge was higher in the teachers with favourable hygiene outcomes. On
the other hand, the teachers who noticed white stick deposits had a significantly (U =
15,517.5; p = 0.019) higher perceived knowledge level. The overall behavior score (0–5)
was weakly correlated with the overall score of perceived knowledge (r = 0.138; p =
0.007) and actual knowledge (r = 0.146; p = 0.004) (Table 8).

Table 8. Impact of elementary schoolteachers’ oral health knowledge on their behaviours.

Variable Outcome Perceived Knowledge Actual Knowledge

Mean SD Significance Mean SD Significance
I have noticed white stick deposits on Agree 15.10 2.86 0.019 5.58 1.61 0.006
my teeth Disagree 14.65 2.38 6.17 1.83
I use a child-sized toothbrush Disagree 14.81 2.67 0.052 5.84 1.73 0.745
Agree 15.60 2.64 5.76 1.71
I have used a dye to see how clean my Disagree 14.91 2.60 0.644 5.83 1.73 0.916
teeth are Agree 14.93 3.58 5.83 1.71
I put off going to the dentist until I have Agree 14.35 2.50 <0.001 5.65 1.64 0.130
toothache Disagree 15.41 2.74 6.00 1.79
I do not worry about visiting the dentist Disagree 14.66 2.72 0.121 5.63 1.77 0.094
Agree 15.06 2.65 5.95 1.69
Total Behavior r. 0.138 0.146
Sig. 0.007 0.004
Mann–Whitney (U) test and Spearman’s correlation (r) test were used with a significance level of 0.05.

3.9. Association of Oral Health Knowledge and Attitudes

The teachers with higher levels of perceived knowledge were significantly more in
favour of the teachers’ role in oral health education (U = 2983.5; p = 0.002), in agree-
ment that teachers should receive oral health training as a part of general health training
(U = 3553.5; p = 0.001), in agreement that oral health can affect the psychology of
schoolchil-dren (U = 2154; p = 0.041), and in agreement that oral health education can
benefit their schoolchildren (U = 699.5; p = 0.001).
Int. J. Environ. Res. Public Health 2021, 18, 6028 12 of 18

While the teachers with higher levels of actual knowledge were significantly more in
agreement that teachers should receive oral health training as a part of general health
training (U = 4016.5; p = 0.016), they were insignificantly more in favour of the teachers’
role in oral health education (U = 3565; p = 0.058), and in agreement that oral health
education can benefit their schoolchildren (U = 1399.5; p = 0.267) (Table 9).

Table 9. Impact of elementary schoolteachers’ oral health knowledge on their attitudes.

Variable Outcome Perceived Knowledge Actual Knowledge

Mean SD Significance Mean SD Significance
Do you think that teachers should have a role in Disagreement 13.10 3.30 0.002 5.24 1.66 0.058
oral health education of schoolchildren? Agreement 15.25 2.60 5.97 1.72
Do you think teachers should receive oral health Disagreement 13.44 3.30 0.001 5.19 1.65 0.016
training as a part of general health training? Agreement 15.33 2.51 6.02 1.73
Do you think oral health can affect the Disagreement 12.89 4.03 0.041 5.94 1.39 0.782
psychology of schoolchildren? Agreement 15.15 2.49 5.88 1.74
Do you think oral health education can benefit Disagreement 10.70 4.00 0.001 5.30 0.95 0.267
your schoolchildren? Agreement 15.14 2.52 5.90 1.72

Mann–Whitney (U) test was used with a significance level of 0.05; Disagreement = Totally Disagree + Disagree; Agreement = Totally
Agree + Agree.

3.10. Determinants of Oral Health Education Experience

The teachers who received education about general hygiene had significantly higher
levels of perceived oral health knowledge (U = 5862; p < 0.001), actual knowledge (U =
8376.5; p = 0.005), and attitudes towards oral health education (U = 7591; p < 0.001).
Similarly, the teachers who received education about oral hygiene had significantly higher
levels of perceived oral health knowledge (U = 4161.5; p = 0.001), actual knowledge (U =
4628; p = 0.008), and attitudes towards oral health education (U = 3938; p < 0.001).
The teachers with higher levels of perceived oral health knowledge were more used to
checking their students’ teeth (U = 4006; p = 0.043), supervising children’s brushing (U =
17751.5; p = 0.485), and teaching their students about oral health (U = 12,153; p = 0.002).
Similarly, the teachers with higher levels of actual oral health knowledge were more used to
checking their students’ teeth (U = 4513; p = 0.252), supervising children’s brushing (U =
13246.5; p < 0.001), and teaching their students about oral health (U = 12,129; p = 0.002).
The more positive attitudes towards oral health education, the higher the frequency
of teachers had checking their students’ teeth (U = 3574; p = 0.005), supervising
children’s brushing (U = 15,479; p = 0.006) and teaching their students about oral health
(U = 11,720; p = 0.001) (Table 10).

Table 10. Impact of elementary schoolteachers’ oral health knowledge and attitudes on their practice.

Variable Outcome Perceived Knowledge Actual Knowledge Attitudes

Mean SD Significance Mean SD Significance Mean SD Significance
Education of general hygiene False 14.59 2.64 <0.001 5.72 1.68 0.005 16.00 2.71 <0.001
True 16.43 2.31 6.34 1.85 17.24 2.30
Education of oral hygiene False 14.78 2.62 0.001 5.74 1.67 0.008 16.06 2.72 <0.001
True 16.19 2.93 6.69 2.05 17.72 1.67
Checking children’s teeth False 14.85 2.58 0.043 5.79 1.71 0.252 16.11 2.68 0.005
True 15.72 3.63 6.28 1.83 17.52 2.36
Supervising children’s brushing False 14.80 2.67 0.485 5.36 1.60 <0.001 15.83 2.80 0.006
True 15.02 2.69 6.27 1.73 16.57 2.52
Teaching oral health False 14.66 2.61 0.002 5.64 1.59 0.002 15.96 2.66 0.001
True 15.55 2.75 6.32 1.95 16.85 2.63

Mann–Whitney test was used with a significance level of 0.05.

Int. J. Environ. Res. Public Health 2021, 18, 6028 13 of 18

4. Discussion
The primary objective of this study was to evaluate the elementary schoolteachers’
level of oral health knowledge, oral hygiene behaviours, and attitudes towards oral health
education. The secondary objectives were to estimate the correlation between teachers’
perceived knowledge and actual knowledge, explore the discrepancies of teachers’ oral
health knowledge, and evaluate the impact of teachers’ knowledge on their behaviours,
attitudes, and practice.
Within the limits of our study, schoolteachers’ overall oral health knowledge was fair,
except for dental trauma management. The correlation between perceived knowledge
and actual knowledge was mainly weak in all the investigated domains. Our teachers’
perceived knowledge was significantly associated with their attitudes towards oral health
education. The higher knowledge levels and the more positive attitudes were significant
predictors for teachers’ actual engagement with providing oral health education to their
children.
Across gender, the female teachers in our sample had significantly higher levels of
perceived oral health knowledge (U = 14,266.5; p = 0.003) and actual oral health knowledge
(U = 14,713.5; p = 0.011) than their male colleagues. The previous studies of elementary
schoolteachers’ oral health knowledge in Saudi Arabia, India, Tanzania, and Uganda found
that female teachers were more knowledgeable than their male colleagues [6,37–43]. While
the difference between female and male teachers in terms of attitudes towards oral health
education was statistically insignificant (U = 17,099.5; p = 0.861), the male teachers had
slightly higher levels of positive attitudes, including the willingness to receive oral health
education. Similarly, in Madinah (Saudi Arabia) and Rungwe (Tanzania), male teachers had
more positive attitudes towards oral health [6,42,43]. The lower levels of males’ perceived
knowledge can be utilised to explain their higher levels of positive attitudes towards oral
health education. Contrarily, in Upper Galilee (Israel) and Al-Kharj (Saudi Arabia), female
teachers had significantly higher levels of both oral health knowledge and attitudes [7,39]. Al-
Jundi et al., 2005 suggested that the female teachers’ positive attitudes could be related to
their caring nature and closeness to children [44].
The private schoolteachers had slightly higher levels of perceived oral health knowl-
edge (U = 7910; p = 0.312) and lower levels of actual knowledge (U = 8212; p = 0.544) com-
pared to the public schoolteachers. Vanka et al., 2012 found that the private schoolteachers
2
in Bhopal (India) had a significantly lower level of oral health knowledge (c = 15.421; p =
0.05) than the public schoolteachers [45]. However, in our sample, private schoolteach-ers
(28.8%) reported more frequently that they received training in general hygiene than the
public schoolteachers (15.6%); there was no significant difference in terms of receiving
training about oral hygiene. Haloi et al., 2014 found that 82.2% of private schoolteach-ers had
postgraduate degrees (PGs), while 65.2% of public schoolteachers held PGs in Mathura
(India); this significant difference was found in our sample as 30.8% of private schoolteachers
hold PGs while only 15% of the public schoolteachers do [46]. Therefore, the improved oral
health outcomes of private school children in some developing countries should be fairly
attributed to the fact that these children come from families with higher socioeconomic
capacities that enable them to cover the tuition fees of private schools [47].
The length of work experience was a significant promoter for the teachers’ perceived
oral health knowledge (U = 14864.5; p = 0.001) and their positive attitudes towards oral
health education (U = 15,917; p = 0.019). The teachers with >10 years of work experience
had significantly higher levels of both perceived knowledge (U = 14,663.5; p < 0.001) and
actual knowledge (U = 15,924; p = 0.007) about what to do in case of dental trauma than their
colleagues with 10 years of experience. This result is consistent with the findings of Junges et
al., 2015 where the elementary schoolteachers with more than 15 years of work experience
were more likely to know the appropriate conduct for handling teeth avulsion and crown
fracture situations, thus suggesting that greater work experience could provide opportunities
for schoolteachers to witness dental trauma events at schools or home [48].
Int. J. Environ. Res. Public Health 2021, 18, 6028 14 of 18

The same conclusion had been previously drawn from cross-sectional studies in
Singapore and Brazil [49,50].
On analysing the relationship between knowledge constructs, the schoolteachers’
per-ceived knowledge and actual knowledge were positively correlated in all the
investigated domains, thus ruling out any critical knowledge discrepancies. Given the low
correlation coefficients found in our sample, the schoolteachers’ perceived oral health
knowledge can weakly predict their actual knowledge; therefore, it should not be
exclusively used to evalu-ate the teachers’ knowledge in future studies. While the mean
score of perceived knowledge was 14.91 2.68 (total 20 points), the mean score of actual
knowledge was 5.83 1.73 (total 10 points), thus suggesting that the perceived knowledge
score (74.6%) was considerably higher than the actual knowledge score (58.3%).
Therefore, the schoolteachers, probably due to their social role as mentors for their
students, are inclined to overestimate their oral health knowledge.
The knowledge domain of “dental trauma management” received the lowest score in
both perceived knowledge and actual knowledge compared to other knowledge do-
mains, thus suggesting that this is the most critical knowledge area that requires urgent
educational interventions for schoolteachers in Turkey. A recent Turkish study found that
pre-schoolteachers had inadequate knowledge about dental trauma management that
might be attributed to lack of trauma experience of the teachers and suggesting the
same call for educational interventions for both schoolteachers and parents on how to
handle dental trauma, which is common in these age groups [51].
In Brazil, physical education undergraduates showed extremely low levels of knowl-
edge about dental trauma [52]. The same was found in Hong Kong and India among
physical education teachers [53,54]. In our sample, physical education teachers had the
lowest frequency of correct answers to the actual knowledge questions of dental trauma
management compared to teachers of other subjects. This finding supports the
abovemen-tioned call for educational interventions, especially for physical education
teachers who are at the greatest risk of encountering dental fractures and avulsion
events as part of their daily work with schoolchildren.
In our study, the schoolteachers with higher levels of perceived oral health knowledge
had significantly higher levels of positive attitude towards oral health education. Ramroop et
al., 2011 found that primary schoolteachers in Trinidad had satisfactory knowledge about
aetiology and the prevention of dental caries, while they had inadequate knowledge about
dental trauma management. In spite of that, Trinidadian teachers had positive attitudes
towards oral health education, suggesting that actual knowledge may not necessarily pre-dict
teachers’ attitudes [55]. In Greece, India, and Nigeria, the schoolteachers’ inadequate
knowledge about oral health was significantly associated with their willingness to learn about
oral health and involved themselves in its teaching [56–58].
However, the overall oral hygiene behaviour score was weakly correlated with the
overall score of perceived knowledge and actual knowledge; teachers’ hygiene
behaviours were not found to be associated with positive attitudes towards oral health
education, nor were teachers’ experience with teaching about oral health. Similarly, in
Saudi Arabia, the high levels of oral hygiene were not associated with positive attitudes
towards oral health education among schoolteachers [39]. These findings contrast with
what was reported earlier by Maganur et al., 2017 in India and Dawani et al., 2013 in
Pakistan, where schoolteachers with good oral hygiene had a significantly higher level of
knowledge and more positive attitudes towards oral health education [59,60]. Our
findings can be either explained as a methodological limitation because the oral hygiene
items adapted from HU-DBI may not have been supposed to be taken out of their
context, or as a true phenomenon where personal oral hygiene of the teachers’ may not
affect their attitudes and practice of oral health education. This point warrants further
investigation to understand better the role of schoolteachers’ oral hygiene in shaping
their students’ oral health behaviours and attitudes.
Int. J. Environ. Res. Public Health 2021, 18, 6028 15 of 18

Our schoolteachers’ perceived oral health knowledge, actual knowledge and

attitudes were significantly associated with their experience of providing oral health
education to their students. This finding highlights the importance of increasing teachers’
awareness through educational interventions as a strategy to increase their likelihood of
providing actual guidance and education to their students.

4.1. Study Limitations

The first limitation of this study is its sample, which was not equally stratified across
gender, but this can be justified as the sample was aimed to be as representative as
possible for the actual demographics of schoolteachers in Turkey who are predominantly
female. The second limitation is that the vast majority of respondents were from public
schools; however, the number of public schools is very close to the number of private
schools in Istanbul. The third limitation was the selection bias, which was unavoidable in
the convenience (non-random) sampling approach that we followed in this study; the
teachers who voluntarily joined the study may have better awareness regarding oral
health and oral hygiene issues.

4.2. Study Strengths

To the best of the authors’ knowledge, this is the first study to evaluate schoolteachers’
oral health knowledge, attitudes, and behaviours in the largest Turkish metropolis (Istan-bul).
It is the first study, to date, comparing teachers’ perceived knowledge and actual knowledge
aiming to explore knowledge discrepancies of the target population. The study provides
support to the prevailing evidence on the role of oral health knowledge in shaping teachers’
attitudes towards oral health education, their oral hygiene behaviours, and their experience
with teaching their students about oral health.

4.3. Study Implications

The findings of this study suggest that future studies of schoolteachers’ oral health
knowledge should discriminate clearly between perceived knowledge and actual knowl-
edge, and they should rely entirely on perceived knowledge outcomes as they can be
overestimated. The schoolteachers, especially physical education teachers, exhibited
low levels of knowledge about dental trauma management, thus calling for urgent
educational intervention to increase their awareness and skills. A conceptual model for
oral health knowledge, attitudes and practice of elementary schoolteachers should be
proposed and tested in the future based on our study data and other similar studies
which employed various oral health constructs, e.g., knowledge, attitudes, behaviours,
etc. This suggested model will serve as a basis for promotion interventions targeting
schoolchildren and their teachers.

5. Conclusions
The elementary schoolteachers in Istanbul, Turkey, showed satisfactory oral health
knowledge and attitudes toward oral health education. The correlation between their
perceived knowledge and actual knowledge was very weak, suggesting that the teachers
are inclined to overestimate their knowledge. The teachers’ knowledge about dental
trauma management was inadequate, necessitating urgent educational interventions,
especially for physical education teachers, who are at the greatest risk of encountering
such events during their work. Female gender and greater work experience were found
to be promoters for oral health knowledge and positive attitudes. The oral hygiene
behaviours were not clearly associated with teachers’ oral health knowledge, attitudes or
practice, thus requiring further investigation.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/ijerph18116028/s1, Questionnaire of Schoolteachers’ Oral Health KAB (in Turkish).
Int. J. Environ. Res. Public Health 2021, 18, 6028 16 of 18

Author Contributions: Conceptualisation, G.Y. and A.R.; methodology, A.R.; validation, G.Y. and
H.K.; formal analysis, A.R.; investigation, G.Y. and H.K.; resources, S.A.; data curation, H.K.;
writing— original draft preparation, G.Y. and A.R.; writing—review and editing, M.K. and S.A.;
supervision, H.K.; project administration, G.Y.; funding acquisition, S.A. All authors have read and
agreed to the published version of the manuscript.
Funding: The work of A.R. was funded by Masaryk University, grants number MUNI/IGA/1543/2020 and
MUNI/A/1608/2020, in addition to the INTER-EXCELLENCE grant number LTC20031.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional Review Board (IRB) of Istanbul Medipol
University Ref. 10840098-772.02-E.34168 on 8 January 2020.
Informed Consent Statement: Informed consent was obtained from all participants involved in
the study.
Data Availability Statement: The data that support the findings of this study are available from
the corresponding author upon reasonable request.
Acknowledgments: The authors thank all the participating teachers for their time and their
eminent support for the study.
Conflicts of Interest: The authors declare no conflict of interest.

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